Lewis_Carly_ClinicalCaseStudy

The Role of Nutrition in Gluten Sensitive PatientsCarly Lewis, UNH Dietetic Intern

April, 2015

What is Gluten?

A protein found in wheat, rye and barley

Helps foods maintain their shape, acting as a glue that holds food together

Can be found in many types of foods, even ones that would not be expected

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Common Sources Wheat Varieties and derivatives of wheat such as:

wheatberries durum emmer semolina spelt farina farro graham KAMUT® khorasan wheat einkorn wheat

Rye Barley Triticale Malt in various forms including: malted barley flour, malted milk or

milkshakes, malt extract, malt syrup, malt flavoring, malt vinegar Brewer’s Yeast Wheat Starch that has not been processed to remove the presence of

gluten to below 20ppm and adhere to the FDA Labeling Law*

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Labeling Rules

Food and Drug Administration Must meet all requirements:

Contain less than 20 parts per million of gluten

Manufactured in a gluten-free facility

If a food does not have a "gluten-free" claim on the package, check directly with product manufacturers for more information

Ingredients such as modified food starch, malt or soy sauce also contain gluten

What Causes Intolerance?

Possibly, the introduction of gluten-containing grains

Grains introduced 10,000 years ago with new agricultural practices

Represented a "mistake of evolution"

Created conditions for human diseases related to gluten exposure

Best known complications are mediated by the adaptive immune system

Wheat allergy

Celiac disease

Celiac Disease

An autoimmune condition that affects one in 133 people

Releases antibodies that attack the intestinal tract

Difficult to absorb nutrients

Causes unpleasant symptoms

Untreated, celiac can also lead to complications

Managing Celiac Disease

Not just eliminating gluten from your diet

Make sure you get all the vitamins and nutrients you need

Watch weight gain

Non-Celiac Gluten Sensitivity

Non-celiac gluten sensitivity (or NCGS) is believed to be more widespread that celiac

Similarity: involves an immune reaction to gluten

Difference: doesn’t produce damaging antibodies

Currently, the only treatment for celiac disease or NCGS is a gluten free diet

There are no established laboratory markers for non-celiac gluten sensitivity

NCGS

Gluten reactions in which neither allergic nor autoimmune mechanisms are involved

Overall clinical picture is less severe

Not accompanied by the concurrence of tTG autoantibodies or autoimmune disease

Ruled out celiac disease, wheat allergy and other clinically overlapping diseases

Type 1 diabetes

Inflammatory bowel diseases

Helicobacter pylori infection

Symptoms triggered by gluten exposure and alleviated by gluten withdrawal

How is it Diagnosed?

Celiac disease

1. A medical review of symptoms

2. A blood test to look for high levels of certain auto-antibodies

3. A biopsy of tissue from the small intestine

NSGS

1. Rule out Celiac Disease and other related disorders

2. Elimination diet and then a “challenge”

What are the Symptoms?

GERD and irritable bowel syndrome (IBS) like symptoms

Abdominal pain

Bloating

Diarrhea, constipation and alternating bowel symptoms

Extra-intestinal manifestations

“Foggy mind”

Headache

Fatigue

Joint and muscle pain

Leg/arm numbness

Eczema/rash

Depression/anxiety

Anemia

Occur soon after gluten ingestion, rapidly improve after gluten withdrawal and relapse in a few hours or days after gluten challenge

Who has to be Gluten Free?

Currently at least 0.5% of the US population follow a GFD without having a confirmed diagnosis of celiac disease

Even in the absence of celiac disease, gluten is thought to be associated with bloating, diarrhea, abdominal pain, fatigue and nausea

Leading to the definition of a new entity (NCGS)

What the Research Suggests

FODMAPs

In addition to gluten, other triggers involved in NCGS pathogenesis have been recently identified

Wheat proteins (i.e. amylase- and trypsin- inhibitors) and

Fermentable oligo-, di-, mono-saccharides and polyols (FODMAPs)

Note: a GFD leads to a significant reduction of dietary FODMAPs

Which leads to an improvement of the GI symptoms of the patients 

FODMAPs

Low FODMAP diet followed

In all participants, GI symptoms consistently and significantly improved during reduced FODMAP intake

Symptoms significantly worsened to a similar degree when their diets included gluten or whey protein

FODMAP Review

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Gut Permeability

The patients who fulfilled the GS diagnostic criteria (see Methods section) experienced symptoms overlapping those presented by CD patients

Their symptoms resolved within a few days after the implementation of the gluten-free diet

They remained symptom-free for the entire follow-up period (up to 4 years)

Those with CD took longer for symptoms to resolve

Symptoms were still present at times even when following GFD

Gluten in the Gut

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Immune Responses

Disappearance of anti-gliadin antibodies of IgG after 6 months of GFD

93.2% of non-celiac gluten sensitivity patients

In contrast, 40% of celiac patients displayed the persistence of these antibodies after gluten withdrawal.

In NSGS patients anti-gliadin antibodies IgG persistence after gluten withdrawal was significantly correlated with the low compliance to gluten-free diet and a mild clinical response.

Immune Response

Both adaptive and innate immunity play a major role in Celiac Disease

Only innate immunity has been thought to be activated by gluten proteins in NCGS

Recent research suggests adaptive immunity may play a role in NCGS

CD is a well-recognized autoimmune disease

Whereas NCGS is likely a gluten hypersensitivity without an established involvement of autoimmunity

Gluten Free Diets and Irritable Bowel Disease

Participants with IBD selected

Diagnosis of CD reported by 10 (0.6%)

Diagnosis of NCGS reported by 81 (4.9%)

314 participants (19.1%) reported having previously tried a GFD

135 participants (8.2%) reported current use of GFD

Adherence was in 41.5%

Average in 34.1%

Fair/poor in 24.4%.

GFD with IBD Continued

Excellent adherence to a GFD associated with reduced fatigue

Compared to fair/poor adherence (p<0.03)

Of all clinical symptoms, only fatigue improved significantly with good adherence

Fatigue in the absence of iron deficiency anemia is a leading symptom in many patients with IBD

Iron absorption is inhibited in those with NSGS and CD

Clinical Recommendations

Clinical Recommendations

Celiac serologies (tTG or DGP) are an important first step in diagnosis

Those with positive serology are highly likely to have CD

Those with borderline serology can undergo HLA typing to determine the need for biopsy

Those with negative serology who also lack clinical evidence of malabsorption and CD risk factors are highly likely to have NCGS and may not require biopsy

Differentiation of CD and NCGS*Nutrient deficiency is defined as vitamin D, iron, vitamin B12, or Zn deficiency

Clinical Recommendations

Patients/Clients with both Celiac Disease and Non-Celiac Gluten Sensitivity should follow a gluten free diet

Eliminates complications of other conditions

Maximizes ability of the gut to absorb and digest

Reduces fatigue

Each individual has a different threshold

More research needs to be conducted on benefits and downfalls of incorporating gluten into the diet of people with NCGS

Case Study

Case Study

56 year old male

Worked in IT department

Now off on disability

Declining activity level over 3-6 months

Spends most days in bed

Recent trouble walking at home, too shaky to use his cane

Marital status: boyfriend for 36 years

Symptoms

Increased confusion, trouble ambulation, chills, fever

Progressive coordination issues

Declining executive function over 48hrs

Presenting Diagnosis

Altered mental status, failure to thrive, severe protein malnutrition

Relevant medical history

Chronic hepatitis C

Oral cancer – palliative chemo and radiation

Hemochromatosis

Celiac disease

Smokes 1-1.5 ppd, excessively drinks (sober for 3 weeks)

Clinical Findings

Confusion

Fever, possible aspiration pneumonia

Possible alcohol withdrawal

Sepsis

Severe protein malnutrition

Cachectic limbs

105lbs – BMI 15.6

Poor dentition

Lab Results

ABG for CO2 narcosis

MELD score of 11

3-month mortality rate of 6%

MRI for possible brain abnormality

CBC

? Sign of aspiration pneumonia

Malnutrition

? Liver dysfunction

Recommended Interventions

Encourage increased protein-energy consumption

Some skin breakdown on sacrum

Address vitamin and mineral deficiencies

Speech therapy evaluation for poor dentition and rotting teeth

Promote gradual weight gain

Possible Gluten-Related Issues

Anemia

Protein-Energy Malnutrition

Neurological changes

Hospital Course

Cognition improved but then declined again

Admitted to the ICU

PEG placed at brother’s wishes

Patient refed after only eating 10-15% of meals during stay

Dispute over plan of care between family and significant other

Ultimately passed away

Questions?

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References: Ansel, Karen. “Does My Child Need a Gluten Free Diet?” Academy of Nutrition and Dietetics. 21

January 2014. Web.

Biesiekierski, Jessica R., et al. “No Effects of Gluten in Patients With Self-Reported Non-Celiac Gluten Sensitivity After Dietary Reduction of Fermentable, Poorly Absorbed, Short-Chain Carbohydrates”. Gastroenterology (2013) 145: 320-328.

Caio, Giacomo, Umberto Volta, Francesco Tovoli, Roberto DeGiorgio. “Effect of gluten free diet on immune response to gliadin in patients with non-celiac gluten sensitivity.” BMC Med (2014) 14: 26.

Herfarth, Hans H., Christopher F. Martin, Robert S. Sandler, Michael D. Kappelman, Millie D. Long. Prevalence of a gluten free diet and improvement of clinical symptoms in patients with inflammatory bowel diseases.” Inflammatory Bowel Diseases (2014) 7:1194-1197.

Kabbani, Toufic A., et al. “A clinical predictive model for differentiation of celiac disease and non-celiac gluten sensitivity. Gastro Journal.

Lauret, Eugenia, Luis Rodrigo. Celiac disease and autoimmune-associated conditions.” BioMed Research International (2013).

Marcason, Wendy. “Understanding Celiac Disease”. Academy of Nutrition and Dietetics. 23 October 2014. Web.

Sapone, Anna, et al. “Divergence of gut permeability and mucosal immune gene expression in two gluten-associated conditions: Celiac disease and gluten sensitivity.” BMC Med (2011) 9: 23.

“Sources of Gluten.” Celiac Disease Foundation. 2015. Web. <http://celiac.org/live-gluten-free/glutenfreediet/sources-of-gluten/>